Entrustable Professional Activities

LG5: Assessment and management - Child maltreatment

Learning Goal 5

Assessment and management of child maltreatment

Develop competence in the identification and clinical management of situations of potential or suspected child harm/maltreatment.

This activity requires the ability to:

  • identify and access sources of relevant information about patients including obtaining and reconciling different accounts of information
  • identify child and family adversity that might lead to child maltreatment
  • perform a comprehensive and wholistic assessment of an infant, child or young person’s presenting concern, overall development, behaviour, learning, and emotional state, taking into account cultural, biological, psychological, and social environmental factors
  • appraise developmental and behavioural status of a child at any age by observation, physical examination, and neurodevelopmental assessment as part of a child maltreatment evaluation
  • recognise, and appropriately respond to, possible indicators of any form of child maltreatment by following local jurisdiction reporting requirements and urgent safety measures
  • select, organise, undertake, and interpret investigations relevant to child maltreatment
  • synthesise findings to develop provisional and differential diagnoses, including medical causes and contributors in the context of child maltreatment presentations
  • formulate an opinion about vulnerability and resilience in relation to children including safety, physical health, development, relationships, behaviour, and psychological wellbeing
  • formulate a defensible opinion regarding the likelihood that a child has experienced maltreatment
  • communicate findings with patients
  • communicate findings to other professionals including producing peer reviewed medicolegal report
  • collaborate with other health professionals and community agencies
  • provide recommendations and facilitate intervention designed to remove the adversity and ameliorate the impact of harm
  • produce comprehensive medical reports, including thorough documentation of findings and justifiable opinions for children in whom a suspicion of any form of child maltreatment has been identified

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • recognise signs of child maltreatment, such as physical abuse, sexual abuse, neglect, emotional maltreatment, exposure to violence, and drug endangerment
  • identify, characterise, and document injuries in children, such as cutaneous injuries, fractures, abdominal and thoracic injuries, head injuries, and genital injuries
  • identify discrepancies between reported mechanism of injury and clinical findings
  • perform detailed and careful examinations for the detection of injury in infants, children, and adolescents including documentation of examination with the adjunct of illustrated body diagrams and photo documentation
  • describe normal anatomical variants and medical conditions that may be causes or contributors to presentations of suspected child maltreatment
  • conduct chaperoned external genital examination in consenting children and adolescents where indicated in the appropriate clinical setting (in line with RACP Guidance on genital examinations)
  • perform a comprehensive assessment of a child’s development, behaviour, learning, and emotions taking into account biological, psychological, comorbidity, and social environmental factors in cases of suspected child maltreatment, including normal and abnormal sexual behaviour development
  • arrange appropriate evidence-based investigations in cases of suspected child maltreatment
  • recognise and appropriately interpret findings of occult injury
  • recognise and appropriately interpret medical tests in cases of child maltreatment
  • engage in post-abuse or neglect treatment and management strategies for patients
  • be aware of protective and resilience factors in the child’s family and/or community, including cultural awareness
  • be aware of and address cumulative harm

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • explain the principles of primary, secondary and tertiary child protection
  • recognise injury types and describe simple injury mechanisms
  • demonstrate ability to formulate differential diagnosis for presentations of child maltreatment
  • demonstrate appropriate escalation for support and supervision to perform examinations in suspected child maltreatment

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • obtain specific informed consent for forensic evaluations
  • perform interviews and examinations around child abuse, neglect, and family violence effectively, including identification of protective factors
  • ask difficult or sensitive questions, and show sensitive engagement of patients in an interview
  • synthesise and interpret findings from the history, examination, and investigations to devise likelihood of child maltreatment
  • clearly document assessment findings in patients’ medical record, including necessary forensic documentation, such as illustrations with diagrams and clinical photography
  • explain outcomes of assessment, diagnosis, and other relevant information to patients and their family or carers and ensure understanding
  • formulate defensible medicolegal opinions based on current literature and evidence
  • produce a peer reviewed medicolegal written report identifying injuries, mechanisms of injuries, likelihood of child maltreatment, and the specific medical needs and recommendations of the child assessed

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • explain the role of child maltreatment specialists, statutory child protection agencies, and police to patients in cases of suspected child maltreatment
  • document objective findings of injuries in children
  • formulate provisional forensic opinions for cases of suspected child maltreatment
  • appropriately report cases of suspected child maltreatment to statutory child protection agencies and identify barriers to reporting

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify limits of expertise and determine the need for child maltreatment specialist referral
  • identify, and respond to, all injuries in pre-mobile infants
  • recognise clinical presentations in which child maltreatment should be a considered differential diagnosis even in the absence of obvious injury, such as:
    • vomiting in infants
    • enlarging head circumference
    • unexplained cardiorespiratory collapse

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise various clinical presentations that may occur because of child maltreatment
  • diligently and efficiently follow local jurisdictional procedures for the notification of suspicions of child maltreatment

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • regularly reflect upon and self-evaluate professional development
  • obtain informed consent before involving patients in teaching and research activities
  • use clinical activities as learning and teaching opportunities, appropriate to the setting and learner
  • use appropriate guidelines and evidence-based medicine resources
  • collaborate with relevant agencies to develop comprehensive and prioritised management plans utilising local resources designed to ameliorate vulnerability, with the aim of reducing the likelihood of physical harm, psychological harm, or inadequate care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • undertake continuing professional development to maintain currency with child maltreatment guidelines
  • reflect on clinical assessment and report writing, and seek feedback from a supervisor

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • analyse relevant literature and refer to evidence-based guidelines in cases of child maltreatment
  • conduct literature review to support medicolegal evidence, both as written reports and oral testimony
  • identify incidence, prevalence, risk, and protective factors of child and adolescent maltreatment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise where evidence is limited, compromised, or subject to bias or conflict of interest

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • reflect on the impact of intergenerational trauma, such as:
    • community violence
    • discrimination
    • impacts of colonisation
    • poverty
    • the mitigation of cumulative risk on adverse childhood experiences
  • observe the complex interactions between the child, siblings, caregivers, support agencies, and the broader social context for protecting children and promoting child wellbeing
  • interpret and explain information to patients at the appropriate level of their health literacy
  • actively support, and effectively use, interpreters and other communication assistance means during every clinical encounter with patients who cannot communicate confidently or verbally in English, and document this in the medical record
  • use qualified language interpreters or cultural interpreters to help meet patients’ communication needs

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • appreciate patients’ cultural and religious backgrounds, attitudes, and beliefs, and how these might influence the response to medical evaluation of child maltreatment

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • apply a broad interview framework with capacity to explore possibility of:
    • fabrication, exaggeration, or induction by the child’s carer of medical symptoms or physical illness
    • inflicted injury
    • neglect of physical, emotional, psychological, nutritional, medical care, or educational needs
    • psychological harm due to the actions of carers
    • sexual abuse
  • obtain informed specific consent from patient and family to conduct general physical examinations, such as photographic recording of injuries, and specific anogenital examinations, including recording using the videocolposcope
  • assess patients’ capacity for decision making, including mature minor and Gillick competence, and involve parents or carers where appropriate
  • demonstrate awareness of complex issues related to sensitive information obtained from child maltreatment evaluations, and subsequent record keeping and information sharing

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • follow regulatory and legal requirements and limitations regarding reporting child maltreatment
  • refer to state based and national laws that impact consent for forensic medical assessment

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify discrepancies between reported mechanism of injury and findings
  • engage children and young people in decision making process at an appropriate developmental level
  • recognise child and family vulnerability for physical harm, psychological harm, or inadequate care
  • respond to suspicions of physical harm, psychological harm, or inadequate care
  • evaluate history and assessment and form an opinion about likelihood of maltreatment based on evidence collected
  • formulate an opinion regarding risk of, and resilience to, adverse outcomes for the subject child, such as:
    • behaviour
    • development
    • physical health
    • psychological wellbeing
    • relationships
    • safety
  • determine the need for referral to subspecialists including child protection or forensic paediatricians
  • consider indications for forensic medical investigations
  • use appropriate guidelines, evidence sources, and decision support tools
  • consider potential bias and gaps in the presentation of history
  • advocate for intervention to prevent further maltreatment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise personal limitations including limitations of expertise and seek help in an appropriate way when required
  • consider the best interests of the child and child safety in decision making

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • conduct appropriate reports to statutory child protection agencies in cases of suspected child maltreatment
  • work collaboratively for child safety with police and statutory child protection agencies
  • involve other professionals, specifically psychosocial allied health professionals, to investigate possibility of psychological and emotional harm
  • collaborate with hospital-based child protection multidisciplinary teams and other government agencies in the evaluation of various forms of suspected child maltreatment

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate awareness of mandatory reporting obligations and local reporting pathways for child maltreatment
  • participate in multidisciplinary child maltreatment meetings

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • apply understanding of the social determinants of health on child maltreatment and long term physical and mental health
  • apply knowledge of the impacts on health and child protection systems responses to child maltreatment from social determinants of health and bias
  • consider the impact of global health threats and emergencies on child maltreatment, such as:
    • climate change
    • natural disasters
    • pandemic
  • promote health and wellbeing of children in special populations, such as:
    • those in foster and out of home care
    • children with disabilities
    • household contacts of identified victims of child maltreatment
  • advocate for appropriate resources to assist families

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate understanding of the social determinants of health at a population level
  • describe the impact of child maltreatment investigations and responses on child wellbeing